MED SURG HESI 250 ACTUAL EXAM QUESTIONS 2024-2025 WITH ALL
ANSWERS VERIFIED & CORRECT
1. What instruction should the nurse include in the discharge teaching plan of a client
who had a cataract extraction today?: Light housekeeping is permitted but avoid heavy
lifting
2. A male adult comes to the urgent care clinic 5 days after being diagnose with influenza.
He is short of breath, febrile, and coughing green colored sputum. Which intervention
should the nurse implement first?: Obtain a sputum sample for culture
3. An elder male client tells the nurse that he is loosing sleep because he has to get up
several times at night to go to the bathroom that he has trouble starting his urinary stream
and that he does not feel like his bladder is ever completely empty. Which intervention
should the nurse implement?: palpate the bladder above the symphysis pubis
4. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract
infection (UTI) Prescriptions for intravenous antibiotics and insulin infu- sion are initiated.
Which serum laboratory value warrants the most immediate intervention by the nurse?:
potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of administration
of a unit of packed red blood cell. When notifying the healthcare provider what
information should the nurse provide first using the SBAR communication process?:
explain specific reason for urgent notification
6. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary
to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this
client for discharge what important aspect regard- ing his medication therapy should the
nurse explain?: It will be necessary to continue prophylactic doses of IV or aerosol
pentamine every month
7. A client subjective data includes dysuria, urgency, and urinary frequency. What
action should the nurse implement next?: collect a clean catch specimen
8. A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?: ask the client in the healthcare provider has
giving her any information about the classification of her cancer
9. A client with a chronic kidney disease is treated on hemodialysis. During the 1
treatment clients blood pressure drops from 150/90 to 80/30 Which action should the
nurse take first?: stop dialysis treatment
10. A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin
sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage
should be increase 900 units/hr. The nurse should program the infusion pump to deliver
how many ml/hr?: 9
,11. The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client sup- ports this diagnosis?:
upper mid abdominal gnawing and burning pain
12. The nurse is providing preoperative education for a jewish client schedule to receive
a xenograft graft to promote burn healing. Which information should the nurse provide this
client?: the xenograft is taken from nonhuman sources
13. A client who took a camping vacation two weeks ago in a country with a tropical
climate comes to the clinic describing vague symptoms and diarrhea for the past week.
Which finding is most important for the nurse to report?: - jaundice sclera
14. During a home visit the nurse assesses the skin of a client with eczema who reports
than an exacerbation of symptoms has occurred during the last week. Which information
is most useful in determining the possible cause of the symptoms?: a grandson and his
new dog recently visited
15. When explaining dietary guidelines to a client with acute glomerulonephri- tis (AGN)
which instruction should the nurse include in the dietary teaching-
: restrict sodium intake
16. A male client who is 24hr post operative for an exploratory laparoctomy complains
that he is starving because he has had no real food since before surgery. Prior to
advancing his diet which intervention should the nurse implememt?: Auscultate bowel
sound in all four quadrants
17. A client diagnose with stable angina secondary to ischemic heart disease has a
prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to
follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart:
call 911 pain is unrelieved and chew a tablet of aspirin 325mg
18. After taking orlistat (Xenical) for one week a femela client tells the home health
nurse that she is experiencing increasingly frequent oily stools and flatus. What action
should the nurse take?: ask the client to describe her dietary intake history for the last
several days
19. Two days after an abscess of the chin was drained the client returns to the
clinic with fever chills and a maculopapular rash with pruritis. The
client has taken an oral antibiotic and cleansed the wound today with provide iodine
(Betadine) solution. Which intervention should the nurse implement first?: assess airway
patency and oxygen saturation
20. A client experiences an ABO incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health care
provider?: low back pain and hypotension
, 21. 1.A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the
intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale
protocol for an isotonic IV solution with regular insulin is prescribed based on the results
of a continuous blood glucose monitoring device that is attached to the client's central
venous catheter. When the client's respirations become labored and his lungs sound
indicate crackles what action should the nurse take?: decrease infusion rate to address fluid
overload
22. When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes
that the previously applied patch is intact on the client's upper back and the client denies
pain. What action should the nurse take?: Apply a new patch in a different location after
removing the original patch
23. A client who had a myocardial infarction is admitted to the coronary critical care unit
(CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was
78/36.What action should the nurse implement?- reduce the rate of the nitroglycerin
infusion
24. An adolescent is admitted to the hospital because of a suicide attempt with an
overdose of acetaminophen (Tylenol). Which blood values are most important for the
nurse to monitor during the first 72 hours following ingestion of this overdose?: LDH OR LD,
SGOT OR ALT, SGPT OR AST
25. An elderly post-operative female client is receiving morphine sulfate via a PCA
pump. Which assessment finding should prompt a nurse to ad- minister the prescribed
PRN medication naloxone?: her respiratory rate is 7 breath/minute
26. Which assessment finding indicates to the nurse that the muscarinic agent
bethanechol (Urecholine) is effective for a client diagnose with urinary retention?: urinary
output equal to intake
27. Following involvement in a motor vehicle collision, a middle aged adult client is
admitted to the hospital with multiple facial fractures. The client's blood alcohol level is
high on admission. Which PRN prescription should be administer if the clients begins to
exhibit signs and symptoms of delirium tremens (DT s)?: Lorazepam (Ativan) 2mg IM
28. Which instructions should the nurse include in the teaching plan of a client who is
taking the diuretic spironolactone (Aldactone)?: Take the medication in the morning
29. A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus.
When should the nurse instruct the client to take the glucagon?: when recognized signs of
severe hypoglycemia occur
30. A client with hyperthyroidism is being treated with radioactive iodine (I-131).
Which explanation should be included in preparing this client for
this treatment?: describe radioactive iodine as a tasteless, colorless medication administered
by the healthcare provide
ANSWERS VERIFIED & CORRECT
1. What instruction should the nurse include in the discharge teaching plan of a client
who had a cataract extraction today?: Light housekeeping is permitted but avoid heavy
lifting
2. A male adult comes to the urgent care clinic 5 days after being diagnose with influenza.
He is short of breath, febrile, and coughing green colored sputum. Which intervention
should the nurse implement first?: Obtain a sputum sample for culture
3. An elder male client tells the nurse that he is loosing sleep because he has to get up
several times at night to go to the bathroom that he has trouble starting his urinary stream
and that he does not feel like his bladder is ever completely empty. Which intervention
should the nurse implement?: palpate the bladder above the symphysis pubis
4. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract
infection (UTI) Prescriptions for intravenous antibiotics and insulin infu- sion are initiated.
Which serum laboratory value warrants the most immediate intervention by the nurse?:
potassium of 2.5 meq/l
5. A client with sickle cell anemia develops a fever during the last hour of administration
of a unit of packed red blood cell. When notifying the healthcare provider what
information should the nurse provide first using the SBAR communication process?:
explain specific reason for urgent notification
6. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary
to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this
client for discharge what important aspect regard- ing his medication therapy should the
nurse explain?: It will be necessary to continue prophylactic doses of IV or aerosol
pentamine every month
7. A client subjective data includes dysuria, urgency, and urinary frequency. What
action should the nurse implement next?: collect a clean catch specimen
8. A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?: ask the client in the healthcare provider has
giving her any information about the classification of her cancer
9. A client with a chronic kidney disease is treated on hemodialysis. During the 1
treatment clients blood pressure drops from 150/90 to 80/30 Which action should the
nurse take first?: stop dialysis treatment
10. A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin
sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage
should be increase 900 units/hr. The nurse should program the infusion pump to deliver
how many ml/hr?: 9
,11. The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client sup- ports this diagnosis?:
upper mid abdominal gnawing and burning pain
12. The nurse is providing preoperative education for a jewish client schedule to receive
a xenograft graft to promote burn healing. Which information should the nurse provide this
client?: the xenograft is taken from nonhuman sources
13. A client who took a camping vacation two weeks ago in a country with a tropical
climate comes to the clinic describing vague symptoms and diarrhea for the past week.
Which finding is most important for the nurse to report?: - jaundice sclera
14. During a home visit the nurse assesses the skin of a client with eczema who reports
than an exacerbation of symptoms has occurred during the last week. Which information
is most useful in determining the possible cause of the symptoms?: a grandson and his
new dog recently visited
15. When explaining dietary guidelines to a client with acute glomerulonephri- tis (AGN)
which instruction should the nurse include in the dietary teaching-
: restrict sodium intake
16. A male client who is 24hr post operative for an exploratory laparoctomy complains
that he is starving because he has had no real food since before surgery. Prior to
advancing his diet which intervention should the nurse implememt?: Auscultate bowel
sound in all four quadrants
17. A client diagnose with stable angina secondary to ischemic heart disease has a
prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to
follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart:
call 911 pain is unrelieved and chew a tablet of aspirin 325mg
18. After taking orlistat (Xenical) for one week a femela client tells the home health
nurse that she is experiencing increasingly frequent oily stools and flatus. What action
should the nurse take?: ask the client to describe her dietary intake history for the last
several days
19. Two days after an abscess of the chin was drained the client returns to the
clinic with fever chills and a maculopapular rash with pruritis. The
client has taken an oral antibiotic and cleansed the wound today with provide iodine
(Betadine) solution. Which intervention should the nurse implement first?: assess airway
patency and oxygen saturation
20. A client experiences an ABO incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health care
provider?: low back pain and hypotension
, 21. 1.A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the
intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale
protocol for an isotonic IV solution with regular insulin is prescribed based on the results
of a continuous blood glucose monitoring device that is attached to the client's central
venous catheter. When the client's respirations become labored and his lungs sound
indicate crackles what action should the nurse take?: decrease infusion rate to address fluid
overload
22. When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes
that the previously applied patch is intact on the client's upper back and the client denies
pain. What action should the nurse take?: Apply a new patch in a different location after
removing the original patch
23. A client who had a myocardial infarction is admitted to the coronary critical care unit
(CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was
78/36.What action should the nurse implement?- reduce the rate of the nitroglycerin
infusion
24. An adolescent is admitted to the hospital because of a suicide attempt with an
overdose of acetaminophen (Tylenol). Which blood values are most important for the
nurse to monitor during the first 72 hours following ingestion of this overdose?: LDH OR LD,
SGOT OR ALT, SGPT OR AST
25. An elderly post-operative female client is receiving morphine sulfate via a PCA
pump. Which assessment finding should prompt a nurse to ad- minister the prescribed
PRN medication naloxone?: her respiratory rate is 7 breath/minute
26. Which assessment finding indicates to the nurse that the muscarinic agent
bethanechol (Urecholine) is effective for a client diagnose with urinary retention?: urinary
output equal to intake
27. Following involvement in a motor vehicle collision, a middle aged adult client is
admitted to the hospital with multiple facial fractures. The client's blood alcohol level is
high on admission. Which PRN prescription should be administer if the clients begins to
exhibit signs and symptoms of delirium tremens (DT s)?: Lorazepam (Ativan) 2mg IM
28. Which instructions should the nurse include in the teaching plan of a client who is
taking the diuretic spironolactone (Aldactone)?: Take the medication in the morning
29. A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus.
When should the nurse instruct the client to take the glucagon?: when recognized signs of
severe hypoglycemia occur
30. A client with hyperthyroidism is being treated with radioactive iodine (I-131).
Which explanation should be included in preparing this client for
this treatment?: describe radioactive iodine as a tasteless, colorless medication administered
by the healthcare provide
